Inquest into the death of Kumarn Rabuntja, Kumanjayi Haywood, Miss Yunupingu and Ngeygo Ragurrk

Contributing factors

• Systemic police failures to assess risk and seek protective orders
• Inadequate JESCC call-taker training and language barriers
• Lack of interpreter services
• Failures to follow domestic violence policies
• Inadequate training in domestic violence identification and trauma-informed response
• Under-resourcing of police, crisis accommodation, and support services
• Failures in child protection agencies to recognise risk or provide appropriate support
• Gaps in health service screening and referral protocols
• Insufficient men's behaviour change programs
• Chronic under-resourcing of correctional services programs
• Alcohol intoxication as an enabler of violence
• Coercive control and family pressure keeping victims in relationships
• Communication barriers and cultural incompetence of frontline workers
• Absence of coordinated whole-of-government response
• Systemic racism and stereotyping of Aboriginal victims and communities

Coroner's recommendations

1. Establish permanent DFSV-ICRO to lead whole-of-government coordination with annual public reporting of statistics and implementation
2. Establish and fund a peak body for DFSV services
3. Amend DFSV Workforce and Sector Development Plan with explicit engagement of local university and communities
4. Increase investment in Aboriginal Interpreter Service with recruitment, training and retention plan
5. Develop and enforce evidence-based alcohol intervention strategy to reduce availability
6. Increase investment in specialist alcohol and other drugs rehabilitation services
7. Fully fund Alice Springs co-responder pilot and replicate in other regions, with consideration of Aboriginal Community Controlled Organisation models
8. NT Police review Supportlink operational protocols and enhance training in when and how to make referrals
9. NT Government consider establishing Multi-Agency Protection Service (MAPS) modelled on South Australian initiative
10. NT Police employ interpreters and/or ALOs in JESCC, embed Aboriginal language speakers in operations, and improve call-taker training
11. Specifically fund and implement PARt training to all NT Police officers, auxiliaries, recruits, and JESCC staff
12. NT Police establish significantly expanded and resourced permanent DFSV Command in Alice Springs and Darwin, with staff continuity protections and internal training unit
13. Expand Family Harm Coordination Project daily auditing program across the Territory
14. DCF conduct audit into Safe and Together Framework implementation
15. Fund and implement timely intensive early interventions for young people involved in DFSV
16. Fund existing and developing community-based approaches to child welfare and research expansion models
17. Expand specialist DFSV court from Alice Springs to Darwin and Katherine with adequate funding for victim/offender support and behaviour programs
18. Fund trained mediators for conflict resolution with cultural and DFSV expertise, including PARt and RAMF training
19. Recognise, regulate, and fund community-led mediation and peacemaker groups as ADR service providers
20. Commit to enhancing, developing, and funding alternatives to custody for DFV perpetrators
21. Review NT Victims Register to implement opt-out system and notify victims of releases on 'time served' and Schedule IIA determinations
22. Consider embedding Charter of Victims' Rights as Part 5A of Victims of Crime Rights and Services Act 2006
23. Ensure increased long-term funding for men's prison-based behaviour programs and counselling with independent evaluation
24. Revise criteria for men's prison-based programs to improve accessibility for remand inmates and those with disabilities
25. Urgently fund development of preparatory counselling/programs for men reluctant to accept responsibility for violence
26. Provide long-term funding for DFSV-specific throughcare and reintegration programs centred on RAMF with safety paramount
27. NT Health continue improving and increase DFSV screening (especially antenatal and emergency), implement PARt and RAMF training, encourage staff to report even when patient claims prior reporting, and fund PARt Consortium pilot
28. Increase remuneration and support terms for Aboriginal Liaison Officers in recognition of cultural expertise
29. Increase funding for existing men's behaviour change programs and community DFSV programs with expansion to remote areas and ACCOs partnership
30. Invest in culturally appropriate prevention and education programs in schools and media on DFSV and respectful relationships
31. Retain independent service provider to fund DFSV awareness training for all licensed clubs and premises with mandating/incentivising through licensing
32. Mandate 12-month trial of BDR scanners in licensed venues for on-premises consumption with independent evaluation
33. Fully implement Action Plan 2 at costed $180 million over five years and $36 million annual ongoing funding (inflation-adjusted)
34. Increase baseline funding for frontline DFSV crisis services by approximately 10% to address core funding deficit
35. Amend NT Government grant guidelines to ensure indexation commensurate with real cost-of-living increases and exempt DFSV services from efficiency dividends